Shoulder Elbow Skeletally Disclosurescme.uthscsa.edu/Courses/SportsMedicine/2016... · Little Leaguer’s Elbow Medial Epicondyle Apophysitis Overuse injury Presentation: • Patients

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Shoulder & Elbowin the Skeletally Immature Athlete

John R. Faust, M.D.

43rd Annual Symposium on Sports Medicine (Jan. 22nd, 2016)

Disclosures

John Faust, M.D., has no financial relationships to disclose

Objectives (20 minutes)Shoulder injuries in skeletally immature athletes:• Relevant anatomy

• Unique injuries• Mimic injuries seen in skeletally mature athletes

Elbow injuries in skeletally immature athletes• Same

OutlineCommon injuries in athletes:

Shoulder• Rotator cuff tendonitis• AC separation

Elbow• Medial ulnar collateral ligament (MUCL) tear

• Lateral epicondylitis (tennis elbow)

Shoulder injuriesin skeletally immature athletes

Mimicker #112 yo male with a “sore rotator cuff”• History:• All‐star pitcher

• Playing every week for the last 12 months

• Lateral shoulder soreness

• Exam:• Full rotator cuff strength with pain

• Tender over lateral shoulder

• Obligate abduction

Diagnosis: rotator cuff tendonitis?


Mimicker #1His radiographs

Diagnosis: proximal humerus epiphysiolysis (little leaguer’s shoulder)

Proximal humerus epiphysiolysis

Our patient Normal 10y 6m male

Proximal humerus epiphysiolysis(Little leaguer’s shoulder)• Often misdiagnosed as rotator cuff tendonitis (seen in skeletally mature athletes)• Rotator cuff tears almost non‐existent in teenagers, partial

thickness tears exist but rarely the whole story and rarely isolated

• Highest incidence in male baseball pitchers ages 11‐16• Peak incidence around puberty at age 14

• Significant shear stress from the high torque in the late cocking/early acceleration phase of throwing• Fastest recorded human motion

Sabick MB, Am J Sports Med 2005; 33: 1716‐1722.

• Thought to be an injury to the proximal humeral physissecondary to torsion and traction • Salter Harris type I equivalent microfractureDotter WE, Guthrie Clin Bull, 1953 Jul;23(1):68‐72.Bishop JY, Clin Orthop Relat Res, 2005 Mar;(432):41‐8.Tullos HS, The Journal of Sports Medicine 1974; 2: 152‐153.Meister K, Am J Sports Med 2000; 28: 587‐601.

(but…)

Proximal humerus epiphysiolysis

Mechanism of physeal stress injuriesSome recent studies define the mechanism of physeal stress injury as:• Begins in the metaphysis with disruption of the normal metaphyseal blood supply• Absent blood flow disrupts endochondral bone formation• Long columns of hypertrophic cartilage cells from the physis extend into the

metaphysis• Cartilage signal intensity of apparent physeal widening seen on MRI• These areas of physeal widening differ from SH‐1 injuries:

• No discrete fracture is identified through the cartilage• Widening can be focal• Neither epiphyseal nor apophyseal displacement is seen

Jaramillo D, Radiology 1993; 187: 171‐178.Laor T, Pediatric Radiology 1997; 27: 654‐662.Laor T, AJR American journal of Roentgenology 2006; 186: 1260‐1264.

• The newly formed metaphyseal bone is fragile and unable to resist compressive, shear or tensile forces making the chondro‐osseous junction (COJ) susceptible to injuryCarter SR, The Journal of Bone and Joint Surgery Br 1988; 70: 834‐836.

• The newly formed metaphysis (primary spongiosa) has only a few mineralized cartilage spikes to provide strength

• The peripheral metaphyseal cortex is thin compared to the cortical thickness of the diaphysis

Shoulder AnatomyProximal humeral physis• Closure begins around 14 yoand finishes by 17 yoKwong S, AJR American Journal of Roentgenology 2014; 202: 418‐425.

• Estimate for complete closure:• 16 yo for females

• 18 yo for males

Growth plate (physis) anatomyEndochondral bone growth• Epiphyseal cartilage turns into mineralized osseous matrix

• Chondrocytes align in columns and progress through defined zones:• Resting• Proliferative• Hypertrophic

• Chondrocytes becoming separated by increasing bands of mineralized cartilage matrix starting in the proliferative zone and increasing in density towards the chondro‐osseous junction (COJ)• These mineralized cartilaginous struts are the surfaces in the metaphysis on which osteoblasts differentiate, produce, and mineralize the extracellular matrix of bone


Proximal humerus epiphysiolysisDiagnosis• History and exam• Radiographs (AP of the bilateral shoulders in external rotation)• MRI rarely needed

Treatment• Rest and structured PT: 2‐3 months

• Throwing program: light tossing then increase distance and velocity

• Education – pitch counts

Natural history• 91% return to sports and remain asymptomatic with structured PT• Long‐term consequences rare due to remodeling potential of the

proximal humerus• 80% of the growth of the humerus is proximal

• Complications rare:• Premature physeal closure length discrepancy, angular deformity• Physeal fracture

Pitch CountsUSA Baseball: web.usabaseball.com• Pitch counts are found in the article “Youth Baseball Pitching Injuries” near the bottom of the Medical Safety Reports page at web.usabaseball.com/about/medical_safety_reports.jsp

USA Baseball and MLB's Pitch Smart website notes: • "Ultimately, it is the responsibility of the parent and the athlete to ensure that the player follows the guidelines for his age group over the course of the year ‐ given that he will oftentimes play in multiple leagues with different affiliations covering different times of the year."

Yeah, right

Mimicker #212 yo male “separated his shoulder”• Tackled playing football, landed on his shoulder• Exam:• Prominent and tender distal clavicle

Mimicker #2His radiograph

Diagnosis: distal clavicle fracture

Red: acromion

Orange: coracoid

Light green: distal clavicle fragment

Green: proximal clavicle fragment

• Distal clavicle ruptures through the periosteum• Significant remodeling potential

Distal clavicle fracture

Periosteum tornPeriosteal sleeve (where the bone will remodel)


Distal clavicle fracturesTreatment:• Initial treatment: sling• Ortho follow‐up with in 1 week

• Definitive treatment: sling vs. ORIF• Age (under/over 13 yo)

• Displacement

• Fracture pattern:• Types I‐III: usually sling

• Types IV‐VI: sling vs. ORIF

Dameron and Rockwood Classification

Elbow injuriesin skeletally immature athletes

Mimicker #112 yo male baseball player

• Best pitcher on the team• Plays on multiple teams year round

• Medial elbow pain after pitching

11 yo female gymnast

• Level 10• Medial elbow pain after floor routines

Diagnosis:medial ulnar collateral ligament tear?

Mimicker #1Radiographs from the 12 yo pitcher

Diagnosis: medial epicondyle apophysitis

Medial Epicondyle ApophysitisHis MRI

Elbow AnatomyMedial ulnar collateral ligament (MUCL)• Proximal attachment to the inferior surface of the medial epicondyle apophysis



• Distal attachment to the sublime tubercle of the ulna and the medial ulnar crest


• Distal attachment to the sublime tubercle of the ulna and the medial ulnar crest

• Anterior band of the MUCL is the primary ligamentous stabilizer of the elbow joint against valgus stress

Elbow anatomyOssification centers (age when appears)• Capitellum (1 yo)

• Radial head (3 yo)• Medial epicondyle (5 yo)• Appears as late as age 7 in males

• Fuses around age 15 in males

• Trochlea (7 yo)• Olecranon (9 yo)• Lateral epicondyle (12‐14 yo)

Mechanics of Pitching Injuries

DiGiovine NM, J Shoulder Elbow Surg 1992;1:15‐25.

Mechanics of Pitching InjuriesPitching mechanics• Late cocking/early acceleration: elbow flexing/extending under valgus stress • Tensile force distracts the ulnar side

• Compressive forces on the radial side

• Abutment/shear of the olecranon on in the trochlea

= Valgus extension overload

Mechanics of Pitching InjuriesShared mechanism of injury / spectrum of injury:

Skeletally immature Both Skeletally mature

Ulnar tension force 1. Medial epicondyle apophysitisMedial epicondyle avulsion fx• Partial• Complete

Medial ulnar collateral ligament (MUCL) tear

Radial compression force

1. Capitellar OCD2. OCD loose body

Radiocapitellar arthritis

Olecranon abutment and shear

Olecranon stress fracture

Olecranon arthritis and osteophytes


Mechanics of Pitching InjuriesAll together: valgus overload syndrome

Valgus extension overload (VEO) stresses the medial epicondyle apophysis• MUCL attaches to the medial epicondyle

• range of injuries referred to as Little Leaguer’s elbow:• Medial epicondylar apophysitis (most common use)

• Accelerated apophyseal growth with delayed closure

• Medial epicondyle avulsion fracture (initial description)• Complete avulsions ‐ true Salter‐Harris I physeal fracture

• Partial avulsions

Little Leaguer’s Elbow

Medial Epicondyle ApophysitisOveruse injury

Presentation:• Patients 5‐15 yo (unfused medial epicondyle), but usually under 10 yo• Insidious or acute onset medial elbow pain

• During pitching or handstands

• Decreased throwing speed• Decreased throwing distance

Imaging:• Radiographs: widening of the medial epicondylar apophysis on radiographs• MRI not usually necessary

Exam:• Medial epicondyle tender

Treatment:• Rest, ice, anti‐inflammatories• Activity modification – no valgus elbow stress

• No throwing, batting okay if no pain• No handstands, floor routine, or vault

• Physical therapy – throwing program, pitching mechanics• Gradual return to sports, pitch counts

Medial Epicondyle Avulsion Fracture

Presentation• Ages 7‐15 yo• 3 mechanisms• Avulsion• Pop and pain

• Elbow buckles while tumbling

• Throwing a fastball

• Dislocation• Direct trauma

10‐20% of pediatric elbow fracture

50‐60% associated with elbow dislocations• Watch for fragment incarcerated in the elbow joint

• Watch for ulnar nerve symptoms

Medial epicondyle avulsion fracture


Fracture displacement• Displaces anterior to the origin on the medial epicondyle• In line with the pull of the flexor‐pronator muscle mass

• Hard to measure on radiographs• Internal oblique view best

• Edmonds E, J Bone Joint Surg 2010;92:2785‐91

• 45° internal oblique, multiply measurement by 1.4 for best estimate• Gottschalk HP, J Pediatr Orthop 2013;33:26‐31

• Exact number needed to indicate surgery not known



Treatment:• Non‐operative:• Brief immobilization for pain then mobilize to avoid stiffness

• Stiffness is the most common complication• Fragment heals anterior MUCL tight in extension loss of

elbow extension• Indications:• Minimal displacement• Non‐athletic types

• Open reduction internal fixation• Secure fixation allows safe and early ROM to avoid stiffness• Indications:• Incarcerated fragment• Open fracture• Throwing athlete, gymnast, upper extremity athlete• Significant displacement (? mm or cm)• Valgus instability• Elbow dislocation?• Ulnar nerve symptoms?

Mimicker #213 yo male baseball player

• Pitcher and catcher• Lateral elbow sore after every game

• No injury

12 yo female gymnast

• Elbow hurts after practice and recently started locking

• No injury

Diagnosis:lateral epicondylitis (tennis elbow)?

Mimicker #2

Diagnosis:Osteochondritis Dissecans (OCD) of the capitellum

Osteochondritis Dissecans (OCD)of the capitellum

Localized disorder of subchondral bone causing separation and fragmentation of the articular surface• Chronic compressive forces at the radiocapitellararticulation• Avascular necrosis of subchondral bone

• Same possible mechanism of injury as physeal stress injuries:• Disruption of blood flow to the secondary epiphysis “metaphysealequivalent”

Laor T, AJR Am J Roentgenol. 2013 Jan;200(1):232.


Presentation:• Overuse injury in gymnasts and throwers

Jones KJ, Ganley TJ, J Pediatr Orthop 2010;30(1):8‐12.

• Dull pain, worse with activity• Popping or locking

Exam• Elbow tender laterally• Asymmetric extension


10y 5m gymnast


Osteochondritis Dissecans (OCD)of the capitellumTreatment• Observation if asymptomatic• Non‐operative: stable lesions

• Activity and weight bearing restriction• Immobilization

• Surgery:• Symptomatic despite immobilization, weight bearing

and activity restrictions• Unstable fragment• Loose body

Surgical options:• Arthroscopy

• Internal fixation• Debridement and marrow stimulation / microfracture

• Osteochondral graftting• Osteochondral autograft

• Mosaicplasty• Osteochondral autograft transfer system (OATS)

• Osteochondral allograft• Best for large, deep, and uncontained lesions

Shi, J Pediatr Orthop 2012Iwasaki ASJM 2006


Treatment• Location important• Contained lesions – surrounded by normal cartilage• Better outcome with marrow stimulation

• Uncontained lesions• Osteochondral grafting

• Worse outcomes:• >50% of the articular surface

• >1 cm diameter

• Uncontained lateral margin

• Return to sports: 25‐86%• Depends on the study and the sport

Panner’s DiseaseAVN of the capitellum ossific nucleus• “Perthes disease of the elbow”• Etiology unclear• Likely due to lateral compression across the radiocapitellar joint

• 4‐8 yo

Difference from OCD• <10 yo• NOT an overuse injury• Benign natural history

Natural history:• Self‐limited• Initial period of fragmentation then normal growth resumes

• Late sequelae rare

Treatment:• Rest then rehabilitation

OCD

Panner’s

Mimicker #310 yo female gymnast

• Lateral elbow pain• Sore during practice• No mechanical symptoms

Diagnosis:lateral epicondylitis (tennis elbow)?

Mimicker #3

Diagnosis:Posterolateral Synovial Impingement

Posterolateral Synovial Impingement

Synovial Impingement of the Posterolateral Elbow (SIPLE)• Plica of the elbow• Often recall an injury• Exam:• Negative for epicondylitis provocative findings

• Tender at posterolateral aspect of the radiocapitellar joint

• Treatment:• Rest, rest, rest

• Physical therapy and mechanics

• Arthroscopic resection (occasionally)


Injuries shared with skeletally mature athletes

Subluxating ulnar nerve

Snapping triceps tendon

Posterolateral rotatory instability (PLRI) (as approaching maturity)

Ulnar collateral ligament (UCL) tear (as approaching maturity)• Majority chronic overuse injuries

• Tommy John procedure (UCL reconstruction)• Performed in 1974, returned to MLB pitching in 1976 with a 10‐10 record, retired after26 years in 1989

Flexor‐pronator tendonitis (as approaching maturity)

SummaryShoulder• Rotator cuff tendonitis

• AC separation

Elbow• UCL tear

• Tennis elbow

Proximal humerus epiphysiolysis(Little Leaguer’s shoulder)

Distal clavicle fracture

Little Leaguer’s elbow(Medial epicondyle apophysitis or Medial epicondyle fracture)

OCD of capitellum orSynovial impingement (SIPLE)

Children are not small adults andthe child athlete is not a little adult athlete

ReferencesKwong S, Kothary S, Poncinelli LL. Skeletal development of the proximal humerus in the pediatric population: MRI features. AJR American Journal of Roentgenology 2014; 202: 418‐425.

Dotter WE. Little leaguer's shoulder: a fracture of the proximal epiphysial cartilage of the humerus due to baseball pitching. Guthrie Clin Bull. 1953 Jul;23(1):68‐72.

Bishop JY, Flatow EL. Pediatric shoulder trauma. Clin Orthop Relat Res. 2005 Mar;(432):41‐8.

Tullos HS, Fain RH. Little league shoulder: rotational stress fracture of proximal epiphysis. The Journal of Sports Medicine 1974; 2: 152‐153.

Meister K. Injuries to the shoulder in the throwing athlete. Part two: evaluation/treatment. The American Journal of Sports Medicine 2000; 28: 587‐601.

Sabick MB, Kim YK, Torry MR et al. Biomechanics of the shoulder in youth baseball pitchers: implications for the development of proximal humeral epiphysiolysis and humeral retrotorsion. The American Journal of Sports Medicine 2005; 33: 1716‐1722.

Jaramillo D, Laor T, Zaleske DJ. Indirect trauma to the growth plate: results of MR imaging after epiphyseal and metaphysealinjury in rabbits. Radiology 1993; 187: 171‐178.

Laor T, Hartman AL, Jaramillo D. Local physeal widening on MR imaging: an incidental finding suggesting prior metaphysealinsult. Pediatric Radiology 1997; 27: 654‐662.

Laor T, Wall EJ, Vu LP. Physeal widening in the knee due to stress injury in child athletes. AJR American journal of Roentgenology 2006; 186: 1260‐1264.

Carter SR, Aldridge MJ. Stress injury of the distal radial growth plate. The Journal of Bone and Joint Surgery Br. 1988; 70: 834‐836.

Furushima K, Itoh Y, Iwabu S, Yamamoto Y, Koga R, Shimizu M. Classification of Olecranon Stress Fractures in Baseball Players. Am J Sports Med. 2014 Jun;42(6):1343‐51.

Laor T, Zbojniewicz AM, Eismann EA, Wall EJ. Juvenile osteochondritis dissecans: is it a growth disturbance of the secondary physis of the epiphysis? AJR Am J Roentgenol. 2012 Nov;199(5):1121‐8. doi: 10.2214/AJR.11.8085. Erratum in: AJR Am J Roentgenol. 2013 Jan;200(1):232.

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Shoulder Elbow Skeletally Disclosurescme.uthscsa.edu/Courses/SportsMedicine/2016... · Little Leaguer’s Elbow Medial Epicondyle Apophysitis Overuse injury Presentation: • Patients